Starting the day off on a ... bad foot

When her heels began hurting, Amy Montemarano did what surveys show most people do.

She tried to ignore it.

She figured her daily running was to blame, so she cut back. Not only did the pain keep worsening, it also spiked after periods of complete inactivity.

“I had to limp when I got out of bed in the morning,” said Montemarano, 42, assistant dean for professional development at Drexel University's Earle Mack School of Law. “The pain radiated up the back of my ankles. Sometimes it throbbed.”

After six months, the Philadelphia resident finally went to a podiatrist. The diagnosis: plantar fasciitis.

Despite the exotic-sounding name, plantar fasciitis is almost as ubiquitous as stinky feet, affecting an estimated 10 percent of American adults. And because the ailment becomes more common with age, creaking baby boomers are swelling the ranks of the gimpy, fueling a booming market for foot-fix products.

Plantar fasciitis occurs when the tough ligament that runs from the heel to the toes on the bottom of the foot – the plantar fascia – becomes irritated and swollen. Both heels may be affected or just one.

Athletes, couch potatoes, weekend warriors, people who are obese or on their feet a lot – in short, just about all upright adults – are vulnerable.

“I was in agony for years,” recalled David Geltzer, a podiatrist who has offices in Philadelphia and Haverford, Pa. “In podiatry school, I was finally diagnosed. I can empathize with my patients.”

Fortunately, studies show that about 90 percent of sufferers eventually get relief from relatively low-tech, low-cost, low-risk treatments such as shoe inserts, stretching exercises, ice packs, night splints and nonprescription pain relievers.

Unfortunately, these remedies require persistence and diligence, as Montemarano learned when she got lax, causing her heel pain to flare last summer after eight years under control.

For those with intolerable, recalcitrant pain, the last resort is surgery to detach part of the fascia or newer, costly sound-wave treatments.

The plantar fascia is a shock absorber, protecting the bones, nerves and muscles of the whole leg while supporting the foot's all-important arch. The fascia connects to the heel bone, which is also connected to the Achilles tendon running down the back of the lower leg.

Like a rubber band, the fibrous fascia can be too tight, too loose or torn, setting the stage for inflammation and discomfort. The soreness may be particularly sharp with the first steps in the morning because the ligament contracts slightly overnight.

Although many patients say their heel pain started out of the blue, the inflammation develops gradually. Among the contributing factors:

Anatomical imperfections, such as high arches, “fallen” arches (flat feet), and tightness of the Achilles tendon or calf muscles.

Biomechanical abnormalities, such as twisting or rolling the foot while walking, called pronation.

Repetitive stress from jobs or sports that involve hours of standing, walking or running on hard surfaces.

Extra weight due to obesity or pregnancy.

Plantar fasciitis is usually diagnosed through a foot exam, plus X-rays to rule out a stress fracture. In half of patients, X-rays reveal calcium deposits known as “heel spurs.” These are generally harmless.

“Twenty years ago, we used to always do surgery to remove the spurs,” said Marlene Reid, a suburban Chicago podiatrist who gives interviews on behalf of the American Podiatric Medical Association. “Now we believe spurs do not cause the pain.”

Indeed, many heel pain therapies are based as much on trial and error as on hard science. No wonder, then, that aging boomers have driven a stampede of new foot-care products such as Dr. Scholl's “massaging gel” insoles, launched with a major ad campaign two years ago.

“There's a huge impact on the market,” Reid said. “I have patients who come in with a bag full of things they've bought online. They've spent hundreds of dollars on stuff that may or may not work.”

Doctors say the following measures work for the vast majority of patients:

Shoe inserts that firmly support the arch and heel. Some studies conclude that off-the-shelf inserts are as effective as customized versions, called orthotics, that are made by a podiatrist and cost several hundred dollars. On the other hand, orthotics are far more durable than pre-made inserts.

Exercises to stretch and strengthen the fascia, Achilles tendon and calf muscles. Ideally, these are done two or three times a day.

Night splints. Worn during sleep, the devices maintain a constant mild stretch of the fascia. Many patients find them uncomfortable.

Joseph Salkowitz, 61, a Philadelphia dentist, has been battling left heel pain for three months. A night splint didn't help, but stretching exercises and a walking cast are bringing relief – as long as he is disciplined.

“I just got tired of wearing” the walking cast, he said, “so yesterday I didn't. Today, my heel is sore. I should probably do the exercises at night, but I just do them in the morning.”

Many patients also benefit from a corticosteroid injection “to break the pain cycle,” said Howard Palamarchuk, sports medicine director at the Temple University School of Podiatric Medicine.

He added that steroids must be used sparingly – no more than three shots over six months – because these powerful inflammation-fighters can shrink the cushion of fat on the heel.

Christopher Daukaus, 45, a Philadelphia Police Department SWAT team member, tried everything – steroids, stretches, orthotics, splints, even acupuncture. Still, he said, after a long day or a game of football “my feet would be on fire, and I'd have them in buckets of ice.”

In the past, the last resort for such a patient was surgery to release part of the fascia from the heel. Surgery is risky; side effects include numbness or fallen arches and yet more pain.

But now sound-wave treatments are available. Daukaus chose high-energy extracorporeal shock-wave therapy. Approved in this country in 2000, it costs up to $2,500 and is not usually covered by insurance.

Paradoxically, the therapy is believed to work by causing micro-trauma to the fascia, thus triggering the formation of blood vessels and stimulating the body's natural healing processes.

Studies of shock-wave therapy have had conflicting outcomes. At Temple, “we haven't seen a lot of good results,” Palamarchuk said.

But the therapy worked for Daukaus.

“I didn't expect anything from it,” he said. “But two days after the treatment, I woke up and thought, 'My feet feel good.' I've haven't had any more problems.”